Appeals Nurse Consultant - Remote
Core
Manage Medicare PAR Provider Post Service payment disputes and appeals by reviewing clinical documentation and applying CMS guidelines.
Role type
Senior IC nurse consultant (utilization management appeals)
Builds
Timely review of PAR provider disputes and appeals across MPO, Coding, DRG, UM Inpatient, and UM Outpatient focus areas
Domain
Healthcare administration, Medicare appeals, Utilization Management
Required skills
Clinical review, CMS guidelines application, medical record analysis, regulatory compliance, case determination, documentation review, standardized template utilization
Preferred skills
Medicare Utilization Management, case review, prior authorization, coding, pre-authorization
Technologies
Computer systems, applications, standardized templates
Responsibilities
Request and research submitted provider clinical information to support case review and determination processes; Review documentation to identify relevant clinical details and apply CMS guidelines, regulatory requirements, and applicable supplemental policies; Prepare comprehensive nurse summaries for medical director evaluation or finalize appeal determinations; Navigate and manage multiple computer systems to ensure timely, accurate, and compliant processing of cases; Perform duties in a fast-paced, sedentary role requiring extended computer use and data entry
Seniority
Mid-level, hands-on IC